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Missed Breast Carcinoma: Pitfalls and Pearls¹

¹ From the Department of Radiology, Medical College of Virginia, Virginia Commonwealth University, 401 N 12th St, Richmond, VA 23298. Recipient of a Certificate of Merit award and an Excellence in Design award for an education exhibit at the 2001 RSNA scientific assembly. Received April 22, 2002; revision requested May 23; final revision received April 25, 2003; accepted April 25. Address correspondence to E.S.d.P. (e-mail: esshawde@hsc.vcu.edu).

View larger version (90K): [in a new window]   Figure 1a.  Invasive ductal carcinoma in a 36-year-old woman with dense breasts and a palpable mass. (a) Left mediolateral oblique mammogram demonstrates no finding that corresponds to a palpable mass (arrow). (b) US image obtained in the area of the palpable abnormality reveals a heterogeneous, hypoechoic mass with irregular margins. Although there is no acoustic shadowing and the mass is wider than it is tall, the hypoechogenicity and irregular margins are suspect for malignancy. Pathologic analysis demonstrated invasive ductal carcinoma.

View larger version (163K): [in a new window]   Figure 1b.  Invasive ductal carcinoma in a 36-year-old woman with dense breasts and a palpable mass. (a) Left mediolateral oblique mammogram demonstrates no finding that corresponds to a palpable mass (arrow). (b) US image obtained in the area of the palpable abnormality reveals a heterogeneous, hypoechoic mass with irregular margins. Although there is no acoustic shadowing and the mass is wider than it is tall, the hypoechogenicity and irregular margins are suspect for malignancy. Pathologic analysis demonstrated invasive ductal carcinoma.

View larger version (96K): [in a new window]   Figure 2a.  Invasive lobular carcinoma in a 40-year-old woman with dense breasts. (a) Right mediolateral oblique screening mammogram shows a small, oval obscured mass superiorly (arrow) that was not seen on the craniocaudal view. (b) US image of the mass demonstrates a simple cyst. (c) US image reveals an incidentally detected irregular mass with acoustic shadowing in the lower outer quadrant. Pathologic analysis demonstrated invasive lobular carcinoma.

View larger version (166K): [in a new window]   Figure 2b.  Invasive lobular carcinoma in a 40-year-old woman with dense breasts. (a) Right mediolateral oblique screening mammogram shows a small, oval obscured mass superiorly (arrow) that was not seen on the craniocaudal view. (b) US image of the mass demonstrates a simple cyst. (c) US image reveals an incidentally detected irregular mass with acoustic shadowing in the lower outer quadrant. Pathologic analysis demonstrated invasive lobular carcinoma.

View larger version (147K): [in a new window]   Figure 2c.  Invasive lobular carcinoma in a 40-year-old woman with dense breasts. (a) Right mediolateral oblique screening mammogram shows a small, oval obscured mass superiorly (arrow) that was not seen on the craniocaudal view. (b) US image of the mass demonstrates a simple cyst. (c) US image reveals an incidentally detected irregular mass with acoustic shadowing in the lower outer quadrant. Pathologic analysis demonstrated invasive lobular carcinoma.

View larger version (142K): [in a new window]   Figure 3a.  Proper positioning. (a) Left mediolateral oblique (left) and craniocaudal (right) mammograms obtained with improper positioning demonstrate poor visualization of the posterior tissue. The margin of a mass is barely perceptible at the edge of the mediolateral oblique image (arrow). (b) On a left mediolateral oblique mammogram obtained with improved positioning, a cancer is seen near the chest wall. An exaggerated craniocaudal view may also help demonstrate such a mass.

View larger version (108K): [in a new window]   Figure 3b.  Proper positioning. (a) Left mediolateral oblique (left) and craniocaudal (right) mammograms obtained with improper positioning demonstrate poor visualization of the posterior tissue. The margin of a mass is barely perceptible at the edge of the mediolateral oblique image (arrow). (b) On a left mediolateral oblique mammogram obtained with improved positioning, a cancer is seen near the chest wall. An exaggerated craniocaudal view may also help demonstrate such a mass.

View larger version (145K): [in a new window]   Figure 4a.  Creative positioning for lesion detection. (a) Bilateral mediolateral oblique mammograms show dense parenchyma with well-defined masses (arrows) and a focal irregular density superoposteriorly on the right side (arrowheads). The well-defined masses proved to be cysts at US. (b) On a right lateromedial mammogram, the irregular density (arrow) has moved upward, a finding that indicates a medial location. At lateromedial mammography, the medial aspect of the breast is closer to the film and can therefore be better evaluated. (c) Spot magnification mammogram (right cleavage view) demonstrates a spiculated mass. Pathologic analysis revealed invasive ductal carcinoma.

View larger version (133K): [in a new window]   Figure 4b.  Creative positioning for lesion detection. (a) Bilateral mediolateral oblique mammograms show dense parenchyma with well-defined masses (arrows) and a focal irregular density superoposteriorly on the right side (arrowheads). The well-defined masses proved to be cysts at US. (b) On a right lateromedial mammogram, the irregular density (arrow) has moved upward, a finding that indicates a medial location. At lateromedial mammography, the medial aspect of the breast is closer to the film and can therefore be better evaluated. (c) Spot magnification mammogram (right cleavage view) demonstrates a spiculated mass. Pathologic analysis revealed invasive ductal carcinoma.

View larger version (119K): [in a new window]   Figure 4c.  Creative positioning for lesion detection. (a) Bilateral mediolateral oblique mammograms show dense parenchyma with well-defined masses (arrows) and a focal irregular density superoposteriorly on the right side (arrowheads). The well-defined masses proved to be cysts at US. (b) On a right lateromedial mammogram, the irregular density (arrow) has moved upward, a finding that indicates a medial location. At lateromedial mammography, the medial aspect of the breast is closer to the film and can therefore be better evaluated. (c) Spot magnification mammogram (right cleavage view) demonstrates a spiculated mass. Pathologic analysis revealed invasive ductal carcinoma.

View larger version (142K): [in a new window]   Figure 5a.  Proper imaging technique. (a) Right craniocaudal screening mammogram obtained in a 65-year-old woman demonstrates underpenetration. (b) Right mediolateral oblique mammogram reveals an irregular density (arrow) that was obscured on the craniocaudal view. (c) Right craniocaudal spot magnification mammogram demonstrates an irregular mass with microcalcifications. At pathologic analysis, the mass proved to be invasive ductal carcinoma.

View larger version (158K): [in a new window]   Figure 5b.  Proper imaging technique. (a) Right craniocaudal screening mammogram obtained in a 65-year-old woman demonstrates underpenetration. (b) Right mediolateral oblique mammogram reveals an irregular density (arrow) that was obscured on the craniocaudal view. (c) Right craniocaudal spot magnification mammogram demonstrates an irregular mass with microcalcifications. At pathologic analysis, the mass proved to be invasive ductal carcinoma.

View larger version (149K): [in a new window]   Figure 5c.  Proper imaging technique. (a) Right craniocaudal screening mammogram obtained in a 65-year-old woman demonstrates underpenetration. (b) Right mediolateral oblique mammogram reveals an irregular density (arrow) that was obscured on the craniocaudal view. (c) Right craniocaudal spot magnification mammogram demonstrates an irregular mass with microcalcifications. At pathologic analysis, the mass proved to be invasive ductal carcinoma.

View larger version (62K): [in a new window]   Figure 6.  Drawings illustrate useful search patterns in mirror image interpretation. CC = craniocaudal, MLO = mediolateral oblique.

View larger version (92K): [in a new window]   Figure 7a.  Mirror image interpretation. (a) Bilateral mediolateral oblique mammograms reveal an irregular mass posteriorly on the left side with a highly suspect appearance (arrow). In addition, a subtle distortion is noted more inferiorly (arrowhead), a finding that becomes more evident with mirror image interpretation. (b, c) On left craniocaudal spot compression mammograms, the posterior (b) and anterior (c) lesions demonstrate a spiculated appearance (arrowhead in c). Pathologic analysis demonstrated multicentric invasive ductal carcinoma.

View larger version (97K): [in a new window]   Figure 7b.  Mirror image interpretation. (a) Bilateral mediolateral oblique mammograms reveal an irregular mass posteriorly on the left side with a highly suspect appearance (arrow). In addition, a subtle distortion is noted more inferiorly (arrowhead), a finding that becomes more evident with mirror image interpretation. (b, c) On left craniocaudal spot compression mammograms, the posterior (b) and anterior (c) lesions demonstrate a spiculated appearance (arrowhead in c). Pathologic analysis demonstrated multicentric invasive ductal carcinoma.

View larger version (103K): [in a new window]   Figure 7c.  Mirror image interpretation. (a) Bilateral mediolateral oblique mammograms reveal an irregular mass posteriorly on the left side with a highly suspect appearance (arrow). In addition, a subtle distortion is noted more inferiorly (arrowhead), a finding that becomes more evident with mirror image interpretation. (b, c) On left craniocaudal spot compression mammograms, the posterior (b) and anterior (c) lesions demonstrate a spiculated appearance (arrowhead in c). Pathologic analysis demonstrated multicentric invasive ductal carcinoma.

View larger version (23K): [in a new window]   Figure 8.  Diagrams illustrate nipple-to-lesion arc measurements used to determine lesion depth. a = distance from nipple to anterior lesion, b = distance from nipple to posterior lesion, CC = craniocaudal, MLO = mediolateral oblique.

View larger version (79K): [in a new window]   Figure 9a.  Multicentric breast cancer in a 63-year-old woman. Right mediolateral oblique (a) and right exaggerated craniocaudal lateral (b) screening mammograms show a prominent area of architectural distortion at the 10 o’clock position (solid arrow). Note also the two small, indistinct masses in the axillary tail (arrowheads) and the linearly arranged microcalcifications at the 7 o’clock position (open arrow). An indistinct high-density node is also seen in the axilla and proved to be malignant at surgery. Pathologic analysis demonstrated multicentric invasive ductal carcinoma and ductal carcinoma in situ.

View larger version (82K): [in a new window]   Figure 9b.  Multicentric breast cancer in a 63-year-old woman. Right mediolateral oblique (a) and right exaggerated craniocaudal lateral (b) screening mammograms show a prominent area of architectural distortion at the 10 o’clock position (solid arrow). Note also the two small, indistinct masses in the axillary tail (arrowheads) and the linearly arranged microcalcifications at the 7 o’clock position (open arrow). An indistinct high-density node is also seen in the axilla and proved to be malignant at surgery. Pathologic analysis demonstrated multicentric invasive ductal carcinoma and ductal carcinoma in situ.

View larger version (102K): [in a new window]   Figure 10a.  Satisfaction of search. Right mediolateral oblique (a) and craniocaudal (b) mammograms demonstrate subtle architectural distortion (arrow) behind an obvious calcified fibroadenoma. The first interpreting radiologist noted the fibroadenoma but missed the distortion, which proved to be invasive ductal carcinoma.

View larger version (73K): [in a new window]   Figure 10b.  Satisfaction of search. Right mediolateral oblique (a) and craniocaudal (b) mammograms demonstrate subtle architectural distortion (arrow) behind an obvious calcified fibroadenoma. The first interpreting radiologist noted the fibroadenoma but missed the distortion, which proved to be invasive ductal carcinoma.

View larger version (106K): [in a new window]   Figure 11a.  Occult cancer with metastases in a 36-year-old woman. (a) Right mediolateral oblique mammogram that was thought to be otherwise negative reveals an enlarged axillary node (arrow) that was palpable. (b) On a right mediolateral oblique mammogram obtained 3 months later while the patient was being evaluated for adenopathy, the previously occult cancer in the 11 o’clock position (arrowhead) became visible. Pathologic analysis demonstrated invasive ductal carcinoma with metastasis to the axilla.

View larger version (101K): [in a new window]   Figure 11b.  Occult cancer with metastases in a 36-year-old woman. (a) Right mediolateral oblique mammogram that was thought to be otherwise negative reveals an enlarged axillary node (arrow) that was palpable. (b) On a right mediolateral oblique mammogram obtained 3 months later while the patient was being evaluated for adenopathy, the previously occult cancer in the 11 o’clock position (arrowhead) became visible. Pathologic analysis demonstrated invasive ductal carcinoma with metastasis to the axilla.

View larger version (108K): [in a new window]   Figure 12a.  Apparent lesion thinning at spot compression mammography. (a, b) Right craniocaudal (a) and mediolateral oblique (b) mammograms demonstrate focal architectural distortion (arrow in a) that may correspond to a superiorly located lesion (arrowhead in b). (c, d) Mediolateral oblique (c) and craniocaudal (d) spot compression mammograms show a persistent but less prominent area of distortion. At 6-month follow-up mammography, the area appeared more prominent, and biopsy was performed. Pathologic analysis demonstrated invasive ductal carcinoma. Rolled craniocaudal views were also obtained and helped confirm the persistence of the lesion.

View larger version (110K): [in a new window]   Figure 12b.  Apparent lesion thinning at spot compression mammography. (a, b) Right craniocaudal (a) and mediolateral oblique (b) mammograms demonstrate focal architectural distortion (arrow in a) that may correspond to a superiorly located lesion (arrowhead in b). (c, d) Mediolateral oblique (c) and craniocaudal (d) spot compression mammograms show a persistent but less prominent area of distortion. At 6-month follow-up mammography, the area appeared more prominent, and biopsy was performed. Pathologic analysis demonstrated invasive ductal carcinoma. Rolled craniocaudal views were also obtained and helped confirm the persistence of the lesion.

View larger version (103K): [in a new window]   Figure 12c.  Apparent lesion thinning at spot compression mammography. (a, b) Right craniocaudal (a) and mediolateral oblique (b) mammograms demonstrate focal architectural distortion (arrow in a) that may correspond to a superiorly located lesion (arrowhead in b). (c, d) Mediolateral oblique (c) and craniocaudal (d) spot compression mammograms show a persistent but less prominent area of distortion. At 6-month follow-up mammography, the area appeared more prominent, and biopsy was performed. Pathologic analysis demonstrated invasive ductal carcinoma. Rolled craniocaudal views were also obtained and helped confirm the persistence of the lesion.

View larger version (120K): [in a new window]   Figure 12d.  Apparent lesion thinning at spot compression mammography. (a, b) Right craniocaudal (a) and mediolateral oblique (b) mammograms demonstrate focal architectural distortion (arrow in a) that may correspond to a superiorly located lesion (arrowhead in b). (c, d) Mediolateral oblique (c) and craniocaudal (d) spot compression mammograms show a persistent but less prominent area of distortion. At 6-month follow-up mammography, the area appeared more prominent, and biopsy was performed. Pathologic analysis demonstrated invasive ductal carcinoma. Rolled craniocaudal views were also obtained and helped confirm the persistence of the lesion.

View larger version (73K): [in a new window]   Figure 13.  Circumscribed cancer in a 63-year-old woman. Right exaggerated craniocaudal lateral mammogram demonstrates a nonpalpable mass in the axillary tail. The mass is lobulated and circumscribed and has high density. Spot compression mammography would help verify the characteristics of the margins. Pathologic analysis demonstrated mucinous carcinoma.

View larger version (144K): [in a new window]   Figure 14a.  Asymmetric density. Bilateral mediolateral oblique (a) and craniocaudal (b) mammograms demonstrate a new focal asymmetric area in the left axillary tail (arrow), a finding that becomes more evident with mirror image interpretation. Biopsy revealed infiltrating lobular carcinoma.

View larger version (130K): [in a new window]   Figure 14b.  Asymmetric density. Bilateral mediolateral oblique (a) and craniocaudal (b) mammograms demonstrate a new focal asymmetric area in the left axillary tail (arrow), a finding that becomes more evident with mirror image interpretation. Biopsy revealed infiltrating lobular carcinoma.

View larger version (97K): [in a new window]   Figure 15a.  Slow-growing cancer. (a) Right mediolateral collimated mammogram shows focal architectural distortion superiorly (arrow). The area was not noted on subsequent images because it had changed imperceptibly. (b) Right mediolateral collimated mammogram obtained 8 years later demonstrates interval growth of the lesion. Biopsy was performed, and pathologic analysis demonstrated tubular carcinoma.

View larger version (108K): [in a new window]   Figure 15b.  Slow-growing cancer. (a) Right mediolateral collimated mammogram shows focal architectural distortion superiorly (arrow). The area was not noted on subsequent images because it had changed imperceptibly. (b) Right mediolateral collimated mammogram obtained 8 years later demonstrates interval growth of the lesion. Biopsy was performed, and pathologic analysis demonstrated tubular carcinoma.